Ventral hernias are among the most common abdominal wall pathologies, and their repair represents a relevant clinical and healthcare challenge. Surgical treatment has evolved with the aim of reducing recurrence, postoperative complications, and associated costs, driving the development of various minimally invasive techniques to optimize clinical and functional outcomes [1].

In this context, extraperitoneal approaches such as transabdominal preperitoneal (TAPP) and totally extraperitoneal variants—including the endoscopic totally extraperitoneal approach (TEA) [2], the subxiphoid top-down endoscopic totally preperitoneal approach (eTPA) [3], and the enhanced-view totally extraperitoneal technique (eTEP) [4]—have been developed. These allow the use of standard meshes without fixation and avoid contact between the prosthesis and the abdominal cavity, showing encouraging results in terms of safety, costs, and postoperative comfort [2–5]. Nevertheless, scientific evidence supporting these extraperitoneal approaches remains limited and largely comes from early series and observational studies [2–5].

This study aims to analyze and compare the outcomes of laparoscopic ventral hernia repair using the transabdominal preperitoneal (TAPP) technique versus a ventral totally extraperitoneal approach performed using a subxiphoid top-down access (eTPA). The purpose is to provide updated evidence to assess the advantages and limitations of each strategy and contribute to the optimization of minimally invasive ventral hernia repair.

A retrospective comparative study based on a prospective database was carried out in a private community hospital between January 2023 and December 2024.

Thirty-three patients were analysed, 18 in the TEP group and 15 in the TAPP group. Demographic and comorbidity characteristics are shown in Table 1. Both groups were comparable regarding age (50.3 ± 13.0 vs. 53.1 ± 12.3 years; p=0.540), sex (61.1% vs. 60% male; p=0.940), and BMI (30.3 ± 3.4 vs. 28.7 ± 2.7 kg/m²; p=0.148). Distribution of comorbidities was similar, with no significant differences in hypertension, diabetes, dyslipidaemia, smoking, or ischaemic heart disease.

Regarding operative variables (Table 2), the proportion of primary and incisional hernias was equivalent. In primary hernias, small defects W1 (0–2 cm) predominated, while all incisional hernias corresponded to W1 (0–4 cm) according to EHS. Operative time was longer in the TAPP group (96.1 ± 14.8 min; 95% CI: 87.8–104.3) compared to TEP (84.7 ± 13.1 min; 95% CI: 78.2–91.3; p=0.029). Mesh area was larger in TEP (242.9 ± 110.3 cm²; 95% CI: 188.1–297.8) than in TAPP (166.9 ± 49.9 cm²; 95% CI: 139.2–194.5; p=0.015).

Rectus diastasis occurred with similar frequency (55.6% in TEP vs. 53.3% in TAPP). However, only patients in the TEP group underwent diastasis plication, which was performed in 11 of the 18 cases (61.1%) (p < 0.001). No plications were performed in TAPP. There was one conversion to IPOM in the TAPP group due to thin peritoneum, with no conversions in TEP.

Postoperative results are detailed in Table 3. No significant differences were observed in postoperative pain, either immediate, at day 7, or at 30 days. Length of stay was slightly longer in TAPP (18.2 ± 5.7 vs. 15.3 ± 4.1 h; p=0.119), without statistical significance. The overall complication rate was low and similar (22.2% in TEP vs. 13.3% in TAPP; p=0.665), mainly mild seromas and haematomas (Clavien–Dindo I). No recurrences were observed at 1-year follow-up in either group.

This study compared two laparoscopic extraperitoneal approaches for ventral hernia repair: transabdominal preperitoneal (TAPP) and totally extraperitoneal repair performed using a subxiphoid top-down endoscopic totally preperitoneal approach (eTPA). Both procedures are relatively novel and represent alternatives to traditional intraperitoneal onlay mesh (IPOM) repair, whose use has declined due to concerns regarding mesh–viscera contact [6]. Available literature remains limited, consisting mainly of initial case series or indirect comparisons with IPOM [2–5]. In this context, the present study is among the first to provide a direct comparison between laparoscopic TAPP and ventral TEP, contributing evidence on their technical characteristics and short-term clinical outcomes.

In our analysis, operative time was longer in the TAPP group. This difference may be related to the need to create and close a peritoneal flap, a technically demanding step that can be particularly laborious when approached laterally from the left flank. Similar observations have been reported in early ventral TAPP series, where peritoneal flap management has been identified as one of the most challenging aspects of the procedure [7]. Conversely, mesh area was larger in the TEP group, likely reflecting the wider dissection enabled by pneumopreperitoneum, which allows broader mesh deployment in the preperitoneal plane. In TAPP, dissection is limited to the extent of the peritoneal flap, which may constrain mesh size, particularly on the contralateral side.

Another relevant technical difference concerns the management of associated rectus diastasis. In the TEP group, diastasis plication was performed when present, as the extraperitoneal midline approach from a subxiphoid access provides direct exposure and favourable ergonomics for midline suturing. However, diastasis closure was partial, since the subxiphoid access requires trocar placement at this level, which limits complete plication up to the xiphoid process. In contrast, in TAPP procedures, correction of rectus diastasis is technically more demanding and less ergonomic due to the lateral approach, which limits manoeuvrability and suturing along the linea alba. These findings suggest that ventral TEP may still offer technical and ergonomic advantages in patients with associated diastasis, despite the limitations inherent to the subxiphoid access, as also reported in recent series [2–5].

From a clinical standpoint, both groups demonstrated low complication rates without significant differences. Observed seromas and haematomas were self-limited and classified as minor (Clavien–Dindo I), in line with previously published experiences [3–5]. The absence of recurrence at 1 year is consistent with early reports showing low recurrence rates when the defect is closed and the mesh is adequately positioned in the preperitoneal space [3–5]. Hospital stay was short in both groups, with no statistically significant differences.

This study has several limitations. Its retrospective, single-centre design may introduce selection bias and limit generalisability. The small sample size reduces statistical power and precludes definitive conclusions. A minimum follow-up of 12 months may be insufficient to fully assess hernia recurrence, which can occur later; however, this reflects an early experience with a relatively novel extraperitoneal technique. In this context, outcomes may be influenced by the surgical team’s learning curve and by the evolution of surgical strategy over time, including a progressive transition between approaches while maintaining similar clinical indications. Accordingly, the results should be interpreted as preliminary and hypothesis-generating, rather than as evidence of superiority of one technique over the other.

In this series, laparoscopic TAPP and ventral TEP approaches were safe and feasible for the repair of small and medium primary ventral hernias and W1 incisional hernias. The TAPP approach was associated with longer operative times, likely related to peritoneal flap creation and closure, whereas ventral TEP allowed wider preperitoneal dissection and the use of larger meshes. In addition, ventral TEP facilitated a more ergonomic midline reconstruction, enabling partial rectus diastasis plication in selected patients.

Given the retrospective design, limited sample size, and relatively short follow-up, these findings should be interpreted as preliminary and hypothesis-generating. Further prospective studies with larger cohorts and long-term follow-up are required to better define the role of each approach. Nonetheless, our results add to the growing body of evidence supporting extraperitoneal techniques as valid and increasingly relevant options in minimally invasive abdominal wall surgery [8, 9].